Key Highlights

Attack of severe pain localized to the unilateral orbital, supraorbital, and/or temporal areas; lasts from 15 minutes to 3 hours. Occurs from once every other day to 8 times per day.

Attacks occur at the same time period for several weeks (the cluster period); accompanied by ipsilateral autonomic signs. Most patients are restless or agitated during attacks compared to people with migraine who often report motion sensitivity during attacks.

Pathophysiology is thought to result from hypothalamic activation with secondary trigeminal and autonomic activation. Cluster period attacks can be precipitated by alcohol, volatile smells, warm temperatures, and sleep.

Diagnosis is based on International Headache Society (IHS) criteria.

Medications for acute treatment should be used in combination with prophylactic medications.

Greater occipital nerve blockade often provides immediate relief until preventive medications take effect. Hypothalamic electrical stimulation has provided dramatic response in patients with chronic cluster headaches that are refractory to less invasive treatments. Other surgical techniques have a poor risk-benefit ratio; destructive surgical techniques are best avoided as they are associated with significant risk of complications.